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  • Washington Highlights

    AAMC Submits Comments on CMS Proposals to Improve Prior Authorization


    Phoebe Ramsey, Director, Physician Payment & Quality
    For Media Inquiries

    The AAMC submitted a March 10 comment letter to the Centers for Medicare & Medicaid Services (CMS) in response to its proposed rule, “Advancing Interoperability and Improving Prior Authorization Processes,” released last December [refer to Washington Highlights, Dec. 9, 2022].

    In its letter, the AAMC applauded the CMS for its efforts put forth in the proposed rule to improve patient care, reduce burden, and to make the prior authorization process more streamlined across all payers. “Rules and criteria for prior authorization must be transparent and available to the physician at the point of care,” the letter stated. “In addition, if a service or medication is denied, both the patient and the physician should be given a specific reason for the denial, information about rights to appeal the decision, and other alternatives that may be covered (e.g., different medications). Medically necessary care should not be denied because a physician and/or patient cannot jump through complicated opaque hoops.”

    Overall, the AAMC’s comments largely supported the proposals to improve prior authorization, particularly the CMS’ inclusion of Medicare Advantage (MA) plans as regulated payers in response to feedback to previous proposals [refer to Washington Highlights, Jan. 8, 2021]. However, the letter recommended that the agency include prescription drugs within the policies to improve prior authorization processing, and as part of the interoperable information to be shared by regulated payers with patients and treating providers, as prescription drugs are an important component of care and a large segment of prior authorization requests. The association’s comments also urged the CMS to finalize more timely decision requirements for payers: 24 hours of receipt of a request for urgent items or services and 48 hours for non-urgent care decisions, rather than the 72 hours and seven days proposed. Coverage decision timeliness is critical for patient care and engagement and must ensure a patient’s timely access to necessary treatment.

    Regarding public reporting and transparency, the AAMC’s letter supported proposals to publicly report prior authorization metrics to shine light on the breadth of utilization management tools across impacted payers. Instead of proposed public reporting at the MA organization level, the comments urged the CMS to require reporting at the contract level to better understand how different plans employ prior authorization requirements. Regarding measurement of providers uptake and use of the proposed Prior Authorization Requirements, Documentation, and Decision (PARDD) application programming interface, the AAMC requested the agency consider an attestation-based approach instead of requiring reporting a complicated and burdensome numerator- and denominator-based measure for the hospital and physician reporting programs.

    The AAMC also provided feedback on accelerating the adoption of standards related to social risk factor data, electronic exchange of behavioral health information, and improving prior authorization for maternal health.